Welcome

Interprofessional Primary Care Team (IPCT) Primary Care Access Clinic Self-Referral Form

By providing your email you agree that GRCHC may contact you using your email for the purpose of providing information regarding specialist appointments, diagnostic testing or information related to our upcoming programs, clinics, and events at GRCHC. You understand that GRCHC cannot guarantee the security of email messages. You understand that email messages may pose a risk to your privacy. You understand at this time, messages from GRCHC will not allow for any email response from you.

Name:

Date of birth (mm/dd/yyyy)

Address

City

Postal Code

Health Card

Email

Phone Number

Pronouns

They/Them

He/Him

She/Her

Family Doctor or Nurse Practitioner Name

Family Doctor or Nurse Practitioner Phone

*

Check this box if you do not have a family doctor or nurse practitioner

Please check the programs you would like to attend:

Prediabetes/Diabetes

Heart Health – blood pressure and cholesterol education

Caring for my COPD

I need to see a doctor or a nurse practitioner for:

Preventative Health Care

Cancer Screening

Support of non-urgent or chronic health conditions

I have the following health care concerns:

Help to Quit Smoking

Pregnancy Support

Well Baby

Child Appointment

Sexual Health

Please check which individual appointments you would like to attend:

Nutrition counselling (Care provided by Registered Dietitians) – Increase your nutrition related knowledge and set lifestyle goals for optimal health.

Mental health counselling – Develop positive coping skills for mental health challenges, such as stress, anxiety, and depression to improve your emotional wellness.

Social prescribing – Establish community connections to reduce loneliness and enhance your social wellbeing.

Please indicate if there is additional information you would like the healthcare provider to know or if you are interested in other health services:

I would like a:

In-person Appointment

Phone Appointment

Virtual Appointment